Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Tuesday, January 22, 2013

Is ADHD a real disorder?

I have deliberately given this post a provocative title to offer a counter weight to the outpouring of news covering the California study demonstrating a close to 25% increase in ADHD diagnosis from 2001 to 2010. I will say at the outset that I am not against medication, and recognize that a small percentage of children who have the diagnosis of ADHD may have a well-defined neurologically based difficulty with focusing and attention. If such a child is already school-age and falling behind academically, treatment with stimulants may protect that child from the damaging effects of low self esteem.

However, for the vast majority of children who have this label, things are much more complex. ADHD is diagnosed by DSM criteria that define the disorder by symptoms alone. In clinical setting in which these diagnoses are made, usually with one 50-minute visit for diagnostic evaluation and subsequent medication checks in 15-30 minutes at 3 month intervals, the child's story is usually not heard.

This story may be of an active, curious boy too restricted by the highly structured setting of today's kindergarten classrooms (a November 2012 study showed that the youngest in the class was 50% more likely to be treated with stimulants for ADHD), or of a child with sensory hypersensitivity who is unable to manage the barrage of sensory stimuli in a lunchroom or hallway.

The story may be one of a child who witnesses domestic violence or a parent who actively abuses alcohol, or both. A child may herself have been abused. In my behavioral pediatrics practice I have listened to countless stories of children, some as young as 2, who has been suspected to have ADHD. I find almost without exception a mulilayered story, sometimes involving multiple generations, that represents a complex interplay of biology and environment. The dignosis of ADHD as defined by DSM in these cases represents an artificial construct.

This past week I attended the National Meeting of the American Psychoanalytic Association in New York. Multiple excellent presentations offered a refreshing change from the oversimplified approach that is now the standard of care in both pediatrics and child psychiatry. Dr. David Mintz, a psychiatrist who has written extensively about what is termed psychodynamic psychopharmacology, in his presentation, entitled "Recovery from Childhood Psychiatric Treatment," addressed the complex developmental meaning of medication. The presentation was filled with rich insights from his research and clinical experience, including, for example, his observation that a pill is often used to localize family pathology in a concrete way in one child.

Another highly instructive presentation came from Jack Novick, co-author with Kerry Kelly Novick of the book Emotional Muscle:Strong Parents, Strong Children, on the out-of control child. I was particularly struck by the opening paragraphs to this presentation, which offered an alternative model, similar to what they describe in their book. The paper is not yet published, but the authors gave me permission to use it. I have included the quote in its entirety, as it is an apt response to the current ADHD study.

Children Out Of Control: Working With Unregulated Affect

Jack Novick and Kerry Kelly Novick

Vulnerable Child Workshop

APsaA, New York, January 2013

There
seems to be an exponential increase in the number of children who are described
by parents, teachers and therapists as out of control. How are we to
understand this kind of behavior, and how as therapists are we able to
intervene and help restore these children to the path of progressive
development? Currently the tendency is to diagnose these children as having
neurological difficulties characterized as ADHD, OCD, executive function
disorder (EFD), pervasive
developmental disorder (PDD), or, increasingly, bipolar disorders.

These children now seldom come for
psychotherapy, but instead are treated by their desperate parents and teachers
with reactive, repressive models of external behavioral controls, almost a
reversion to 19th-century modes of authoritarian domination. More
perniciously, there is an explosive increase in the prescription of stimulant,
anti-anxiety and antidepressant medications, as well as widespread off-label
use of antipsychotic drugs. The assumption seems to be that there is a
one-to-one relationship between atypical behavior and some specific brain
disorder. This of course is the age-old dream of finding a single cause in the
body or the mind.

Recent
neuroscience investigations, utilizing advances in the development of computer
algorithms for classifying MRI images, have made possible large scale studies
of normal and atypical brain development. These are able to capture any changes
associated with these diagnoses. In an overview of such studies the authors
conclude, "There is no identified 'lesion' common to all, or even most,
children with the most frequently studied (psychiatric) disorders"

Ignoring
such findings, pediatricians, psychiatrists and other clinicians continue to
prescribe at ever-growing rates. ADHD and bi-polar diagnoses and their
accompanying prescriptions have increased drastically in the past twenty years.
2.5 million American children are medicated for ADHD (10% of all 10-year-old boys); between 1994 and
2003 the number of children diagnosed with bi-polar disorder increased 40-fold. The proportion of underprivileged and minority children sedated
for life is a blot on our health system, a social/political disgrace, and a
permanent drain on our economy. Despite all the millions spent by
pharmaceutical companies in marketing these drugs, the number of children
struggling with such troubles continues to rise. If this rate of treatment
failure occurred with a strictly medical treatment, the drugs would be
withdrawn.

3 comments:

"...a pill is often used to localize family pathology in a concrete way in one child." Nice to see that Dr. Mintz has discovered the concept of the "identified patient" from the family systems model. It's been around for decades. Family Systems is still a sadly neglected model by mainstream psychiatrists and psychologists alike.

Thank you for this very informative blog. In response to the role family dynamics plays in the presentation of a dysregulated child, I advocate always using a play activity to assess the family whenever a child presents for treatment. This way contributing factors from the family system can be taken into account when considering a diagnosis. I have been doing this for over 20 years and it is invaluable.

the baby connects

About Me

I am a pediatrician and author of Keeping Your Child in Mind: Overcoming Defiance, Tantrums, and Other Everyday Behavior Problems by Seeing the World Through Your Child's Eyes (2011) and the forthcoming Listening to Parents and Children: Protecting Space and Time for Growth, Healing, and Resilience. I have a longstanding interest in addressing children's mental health needs in a preventive model. I have over 20 years experience practicing both general and behavioral pediatrics, and I currently run the Early Childhood Social Emotional Health Program at Newton-Wellesley Hospital. I am on the faculty of the Berkshire Psychoanalytic Institute and the Brazelton Institute. I am a graduate of the University of Massachusetts Infant-Parent Mental Health Post-Graduate Certification Program.